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Directing traffic

A triage shift helps hospitalists avoid "tunnel vision"

May 2010

Published in the May 2010 issue of Today’s Hospitalist

BEFORE JEFFEREY WINNINGHAM, MD, began working as a hospitalist in 2000, he put in three years as both a primary care physician and an intensivist. But as director of the hospitalist team at Providence Regional Medical Center in Everett, Wash., many of the hospitalists he hires are straight out of residency and have never clocked time in an outpatient practice.

Dr. Winningham says he’s concerned that internists who work only on the inpatient side of medicine can become “isolated and develop tunnel vision.” Combine that with the fact that many outpatient physicians enter practice with no inpatient experience beyond their residency, and the potential for misunderstandings on both sides of the inpatient-outpatient divide is high.

That’s a problem, Dr. Winningham points out, because “transition points are the most crucial times in terms of liability and patient safety.” To bridge that gap, the hospitalists at Providence Regional take a unique approach to doing triage, whether it’s patients coming from the ED, direct admits from primary care physicians or specialists, or transfers from other hospitals: They all take a turn. Dr. Winningham says that one goal of having a triage shift is to help hospitalists appreciate the issues their counterparts face on the other side.

Pressures on other physicians
At Providence Regional, the hospitalist group now includes 38 physicians (who make up 34 full-time equivalents) and four advanced registered nurse practitioners. The group admits virtually all the hospital’s patients and provides 24/7 coverage.

The role of the triage physician evolved as the group grew and started working around the clock. The hospital’s answering service always knows in advance who is serving as triage physician for any particular shift.

When hospitalists are serving in the triage role, their census runs between four and six patients. At night, however, triage physicians devote themselves exclusively to cross coverage and take no admissions, which are instead handled by the group’s nocturnists. Triage physicians at night take pages and do bedside evaluations.

Dr. Winningham says that everyone “including him “shares in the rotation, one in which the triage doctor assigns admitted patients among team members and decides where in the hospital ” ward, ICU, ED or observation unit for chest pain or TIA “patients are going to go. Working triage helps hospitalists understand the world of the ED and outpatient physicians who call in.

“We sometimes have to guide outpatient physicians as to whether patients really have to come in, either to the ED or as a direct admission,” Dr. Winningham points out. “We may be able to say, ‘This chronic anemia patient sounds like he’s doing fine, so we can set him up for an outpatient transfusion or outpatient iron therapy. Here’s how we can help arrange that for you.’ ”

The triage role has become even more challenging in the past several years as Providence Regional has moved to become a regional referral center, particularly for cardiology and oncology, accepting referrals from smaller hospitals in several different counties.

A stressful job
Hospitalists pull the triage shift only two or three days in a row, usually once a month. (Group members typically work five days in a block.)

Hospitalists’ exposure to the triage role is limited because it can be very stressful, Dr. Winningham says. Not only does it tax physicians’ medical decision-making, but it puts them in the role of being, for that day or two at least, “the public face of the team,” he points out. “The challenge is to make sure that we are service-oriented and customer-friendly, and to learn how to say ‘yes’ and ‘no’ at the same time.”

Because the rotation is so challenging, new hires aren’t scheduled to work triage until they’re well up to speed. “We reserve triage until after they’ve been here a few months,” Dr. Winningham says. “There are a lot of moving parts to doing it.”

But the group feels that the role also has big payoffs. For one, as the triage doctor, hospitalists get to know the providers in the community.

And hospitalists get a much better sense, Dr. Winningham explains, of “how hospitals work. The complexity of inpatient care is always changing.”

The value of a physician rotation
Dr. Winningham admits that occasionally, team members point out that some of them are much better at filling the triage role than others. It’s been suggested that those physicians who are most skilled at triage should pull the shift more often “and get paid more.

“That’s a valid argument,” says Dr. Winningham. “But the flip side is that by not sharing the rotation, physicians are going to think less about what happens with those patients on the outside.” When doctors are triaging patients that their colleagues have to take care of, he adds, “there’s a connection to be made.”

Other groups, Dr. Winningham points out, have nurse practitioners fill that triage role, but he takes a different view. “You need to expect the unexpected,” he says.

“Even when patients sound straightforward, they can be much sicker than represented on the phone,” he says. “We’ve decided to keep triage with the physicians because the spectrum of calls and of pathology is incredibly broad.” While the group hasn’t completely ruled out the possibility of using NPs for triage, he adds, “unless it was a two-tiered triage system, we’ll continue to channel it through physicians.”

And now that the Centers for Medicare and Medicaid Services has expanded the list of conditions that may be more appropriate for observation than for inpatient admission, Dr. Winningham says, triage will become more critical.

The hospitalists now staff the Providence Regional observation unit, which handles chest pain and TIA patients. But the group is looking to expand that unit over the next year to include syncope, certain COPD cases and perhaps even delirium patients. In helping decide which of these patients should be in observation, the triage doctor will become even more important.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.